Laparoscopic Hysterectomy

Definitions:

Hysterectomy = removing uterus

Salpingectomy = removing tubes

Oophorectomy = removing ovaries

Bilateral = both sides

Hysterectomy is the surgical removal of the uterus. It is often performed for abnormal bleeding or pelvic pain. Removing the uterus is a separate procedure from removing the ovaries. Because the ovaries are left in place, they continue to make hormones, and a person who has their uterus removed does NOT go into instant menopause. They continue to have hormone production, they just no longer have periods. A hysterectomy can be performed through the vagina (total vaginal hysterectomy), through an open incision (laparotomy)--(ex. abdominal hysterectomy) or laparoscopically (through small incisions in the abdomen). The differences between laparoscopic hysterectomy are explained below.

Total Laparoscopic Hysterectomy (TLH) means removing the uterus and cervix using laparoscopy, with the uterus and cervix being removed through the vagina and then the vaginal cuff is closed. It takes 6-8 weeks for the vagina to heal after TLH. During this time, you should not have intercourse, or do strenuous exercise or heavy lifting (>10#). Because the cervix is removed, you no longer have to have pap smears. There is a small risk of an infection or a blood clot forming at the top of the vagina after surgery. There is also a small risk of the vagina separating after surgery, which would need to be repaired surgically, resulting in a prolonged recovery.

Small risk of vaginal cuff separation which would require additional surgery

Laparoscopic Supracervical Hysterectomy (LSH) is when the uterus is removed laparoscopically. The uterus is detatched from the surrounding tissues, then removed through small pieces through one of the small ports (usually in the belly button). This process is called morcellation. The cervix is left in place. Although most uterine fibroids are benign (>99%), there is a rare type of uterine fibroid cancer (leiomyosarcoma). There is not a way to predict who will have this prior to surgery. Because of this, there is a small risk that if leiomyosarcoma is present, and the tissue is removed though small strips, then the cancer could spread throughout the abdomen. This may worsen the prognosis by several months. It is estimated that the risk of leiomyosarcoma is 1 in 350 in women undergoing surgery for fibroids.

One benefit of LSH is a very quick recovery—usually 2 weeks. There is also a lower risk of surgical complications such as infection or blood clot at the top of the vagina.

Pros:

Quicker recovery

Lower risk of surgical complications

Cons:

2-3% chance of irregular spotting or staining

You need to continue to have pap smears for cervical cancer screening

Small risk of dissemination of undiagnosed uterine fibroid cancer

Removing Tubes or Ovaries

Bilateral salpingectomy (removing both Fallopian tubes)

Recent studies show that a lot of ovarian cancer actually starts in the tubes. If the tubes are removed at the time of hysterectomy, it lowers the risk of ovarian cancer by 65%. It takes approximately an extra 3-4 minutes in the operating room, without extra recovery. There does not seem to be a benefit to keeping your tubes if you are done having children.

Risks vs. Benefits of Removing Ovaries

Benefits:

Drastically reduces risk of ovarian cancer

Prevents possible need for future problems with ovarian cysts or pelvic pain, which may require ultrasounds or future surgery

Decreased risk of breast cancer if ovaries are removed before menopause

Risks:

Increased risk of heart disease and stroke

Increased of metabolic syndrome (high blood pressure, pre-diabetes)

Increased risk of death (In general, women die 1-2 years earlier if there ovaries are removed at time of hysterectomy.)

Laparoscopy

Laparoscopy is a minimally-invasive surgery that uses a thin, lighted tube put through a cut (incision) in the belly to look at the female pelvic organs . Laparoscopy is used to find and remove problems such as ovarian cysts, adhesions (scar tissue), fibroids, and endometriosis. Tissue samples can be taken for biopsy. Because laparoscopy is a less-invasive form of surgery, it is associated with less pain and a quicker recovery compared to traditional surgery.

Laparoscopy is a minimally-invasive surgery that uses a thin, lighted tube put through a cut (incision) in the belly to look at the female pelvic organs . Laparoscopy is used to find and remove problems such as ovarian cysts, adhesions (scar tissue), fibroids, and endometriosis. Tissue samples can be taken for biopsy. Because laparoscopy is a less-invasive form of surgery, it is associated with less pain and a quicker recovery compared to traditional surgery.

Stop aspirin, ibuprofen (Advil, Motrin), or naprosyn (Aleve) 1 week prior to surgery, as these increase the risk of bleeding. Tylenol is fine to use during this time.

Do not eat or drink anything after midnight the night prior to your surgery, unless instructed by the hospital (for example, patients who have surgeries scheduled later in the afternoon are often allowed to drink clear liquids up to 6 hours before their scheduled surgery)

Clear liquids include apple juice, soda, coffee or tea without milk or creamer

Inform your physician if you take Plavix, Coumadin, Xaralto, or any medicine that increases bleeding

Stop all herbal and vitamin supplements 1 week prior to surgery

Prescribed medications can usually be taken the morning of surgery with a small sip of water. It is important to take blood pressure medications on the day of surgery with a small sip of water. Most other prescription medications do not need to be taken on the day of surgery.

Inform your physician if you have had a problem with anesthesia in the past, other than nausea or prolonged time to wake up

Inform your physician if you have had a blood clot in the leg in the past, for which you had to take blood thinner medications, or if you have a bleeding disorder, or a cardiac murmur for which you take antibiotics every time you have a procedure done or go to the dentist

Postoperative:

Take ibuprofen (Advil or Motrin) 600mg every 6 hours over the counter for pain, or Aleve, 2 pills every 12 hours.

If you are still in pain, take Percocet or Vicodin in addition to ibuprofen or Aleve. Do not take Tylenol if you are taking Percocet or vicodin, as they both contain Tylenol.

You can also take ibuprofen or Aleve, and Extra-Strength Tylenol (1000mg every 6 hours) instead of taking Percocet or Vicodin

Constipation is common after laparoscopy due to the narcotics received. To prevent this, use Miralax (an over the counter laxative), 1 capful 2 times per day until you have normal bowel movements. It is very important not to get constipated after surgery as this can significantly increase pain. You can also use colace (a stool softener over the counter) 100mg twice a day, or Milk of Magnesia if needed (follow directions on bottle).

Shoulder pain is common after laparoscopy due to irritation of the diaphragm which refers pain to the shoulder from gas used during surgery. Take pain medications and usually this resolves in 1-3 days.

Incisions are closed with surgical glue. Do not pick at the glue or apply anything else to the incisions. The glue will fall off in 1-2 weeks. It is fine to get your incisions wet, just make sure they are dried off very well after the shower.

No bathing or swimming for 2 weeks after surgery (showers are fine starting the day after surgery)

It is normal to have spotting or light bleeding for several days, up to 1 week.

No tampons, douching, or sexual intercourse for 2 weeks after laparoscopy

Do not lift anything heavier than 10 pounds, or perform strenuous exercise for 2 weeks. Brisk walking is fine. Listen to your body—if you are in pain, then you need to slow down and rest. If you overdo it, you can break a stitch in the incision, and cause a hernia, or break an internal blood vessel causing a complication.

Rules for driving: Do not drive if you are taking a narcotic (Percocet or Vicodin). When you are in the car in your driveway, slam on the brake. If you feel pain, you should not be driving. Most people can drive 10-14 days after laparoscopy. It is fine to go on errands starting 2-3 days after surgery as long as someone else is driving.

It is fine to go up and down stairs starting the day of surgery.

There is an increased risk of developing a blood clot in the leg after surgery. The best way to prevent this is to walk around

Concerning symptoms:

Please call the office right away if you have:

Fever > 100.4

Persistent vomiting

Worsening pain

Heavy vaginal bleeding (saturating a pad an hour for more than 2 hours)

Redness around 1 incision, or pus coming from the incision

Risks of surgery:

All surgery has a small risk of complications. These include but are not limited to bleeding which may require a blood transfusion, infection, injury to other structures (bowel, bladder, blood vessels, ureters), problems with anesthesia, blood clot in the leg, or nerve injury. The risk of any of these things happening is approximately 1%. We take every possible precaution to prevent surgical complications.

Your health is our priority. Please ask if you have any questions regarding the benefits of laparoscopy, the risks, or any alternative options.

Laparotomy

A laparotomy is a surgical procedure involving an incision through the abdominal wall to gain access into the abdominal cavity and female pelvis. It is often required when a very large pelvic mass (ex. ovarian cyst or large fibroids) needs to be removed. Depending on the anatomy, the procedure can often be performed through a mini-laparotomy, which is a small 2-3 inch incision. Most patients spend 1-2 nights in the hospital after a laparotomy, and it can take up to 6 weeks for complete healing.

Stop aspirin, ibuprofen (Advil, Motrin), or naprosyn (Aleve) 1 week prior to surgery, as these increase the risk of bleeding. Tylenol is fine to use during this time.

Do not eat or drink anything after midnight the night prior to your surgery, unless instructed by the hospital (for example, patients who have surgeries scheduled later in the afternoon are often allowed to drink clear liquids up to 6 hours before their scheduled surgery)

Clear liquids include apple juice, soda, coffee or tea without milk or creamer

Inform your physician if you take glucophage, Plavix, Coumadin, Xaralto, or any medicine that increases bleeding

Stop all herbal and vitamin supplements 1 week prior to surgery

Prescribed medications can usually be taken the morning of surgery with a small sip of water. It is important to take blood pressure medications on the day of surgery with a small sip of water. Most other prescription medications do not need to be taken on the day of surgery.

Inform your physician if you have had a problem with anesthesia in the past, other than nausea or prolonged time to wake up

Inform your physician if you have had a blood clot in the leg in the past, for which you had to take blood thinner medications, or if you have a bleeding disorder, or a cardiac murmur for which you take antibiotics every time you have a procedure done or go to the dentist

Postoperative:

Take ibuprofen (Advil or Motrin) 600mg every 6 hours over the counter for pain, or Aleve, 2 pills every 12 hours.

If you are still in pain, take Percocet or Vicodin in addition to ibuprofen or Aleve. Do not take Tylenol if you are taking Percocet or vicodin, as they both contain Tylenol.

You can also take ibuprofen or Aleve, and Extra-Strength Tylenol (1000mg every 6 hours) instead of taking Percocet or Vicodin

Constipation is common after laparoscopy due to the narcotics received. To prevent this, use Miralax (an over the counter laxative), 1 capful 2 times per day until you have normal bowel movements. It is very important not to get constipated after surgery as this can significantly increase pain. You can also use colace (a stool softener over the counter) 100mg twice a day, or Milk of Magnesia if needed (follow directions on bottle).

Incisions are closed with surgical glue. Do not pick at the glue or apply anything else to the incisions. The glue will fall off in 1-2 weeks. It is fine to get your incision wet, just make sure they are dried off very well after the shower.

No bathing or swimming for 6 weeks after surgery (showers are fine starting the day after surgery)

It is normal to have spotting or light bleeding for several days, up to 6 weeks.

No tampons, douching, or sexual intercourse for 6 weeks after laparoscopy

Do not lift anything heavier than 10 pounds, or perform strenuous exercise for 6 weeks. Brisk walking is fine. Listen to your body—if you are in pain, then you need to slow down and rest. If you overdo it, you can break a stitch in the incision, and cause a hernia, or break an internal blood vessel causing a complication.

Rules for driving: Do not drive if you are taking a narcotic (Percocet or Vicodin). When you are in the car in your driveway, slam on the brake. If you feel pain, you should not be driving. Most people can drive 10-14 days after laparoscopy. It is fine to go on errands starting 2-3 days after surgery as long as someone else is driving.

It is fine to go up and down stairs starting the day of surgery.

There is an increased risk of developing a blood clot in the leg after surgery. The best way to prevent this is to walk around

Concerning symptoms:

Please call the office right away if you have:

Fever > 100.4

Persistent vomiting

Worsening pain

Heavy vaginal bleeding (saturating a pad an hour for more than 2 hours)

Redness around 1 incision, or pus coming from the incision

Risks of surgery:

All surgery has a small risk of complications. These include but are not limited to bleeding which may require a blood transfusion, infection, injury to other structures (bowel, bladder, blood vessels, ureters), problems with anesthesia, blood clot in the leg, or nerve injury. The risk of any of these things happening is approximately 1%. We take every possible precaution to prevent surgical complications. Your health is my priority. Please ask me if you have any questions regarding the benefits of laparoscopy, the risks, or any alternative options.

Essure

Essure is a minimally-invasive way of tying your tubes (permanent sterilization). It should only be performed in women who never want to have more children.

In the procedure, a small camera (hysteroscope) is placed through the cervix into the uterus. Small flexible metal coils are then placed in each opening of the tube into the uterine cavity. The procedure is performed in the office, and it can be done under local anesthesia (the cervix is numbed & you are given an injection of Toradol, like a strong Advil), or under IV sedation (twilight). If you choose local anesthesia, you can drive yourself home. If you choose IV sedation, you will need a ride home, and you should plan to sleep or rest for the remainder of day.

Most patients experience mild to moderate cramping for 1 day after Essure is performed. It takes 3 months for tissue from the tubes to grow into the coils and block the tubes. It is very important to use another method of birth control during this time. 3 months after Essure is performed, an X-ray dye test (hysterosalpingogram) will be performed to make sure the tubes are occluded.

Once it is confirmed that the tubes are blocked, contraception is no longer necessary. Condoms are still advised for protection against STDs if you are not in a mutually monogamous relationship.

There are risks and benefits of having Essure performed.

Benefits:

Permanent birth control.

Hormone-free.

Minimal pain during procedure.

Quick recovery.

Risks:

With any procedure, there is a risk of bleeding, infection, problems with anesthesia, or injury to surrounding structures. If uterine perforation occurs (when an instrument goes through the back wall of the uterus), Essure cannot be performed. Rarely additional surgery will be necessary. The chance of any of the above risks occurring is approximately 1%.

There is a small chance (up to 3%) of the coils perforating (going through) the tubes. If this occurs, then Essure will not be effect for birth control, and you may need a laparoscopy to remove a coil if it is in the abdominal cavity.

Pelvic pain can occur in some women after placement of Essure. It is unclear why this occurs. If the pain is significant, then laparoscopic removal of the tubes or even hysterectomy (removal of the uterus) may be necessary. If hysterectomy is required, the ovaries are left in place so that you do not undergo instant menopause.

Conclusion:

Essure is overall a safe, effective, hormone-free method of permanent birth control. There are some potential risks, and each patient needs to be aware of them. Most women who have Essure are happy they chose to have it performed.

Endometrial Ablation

Endometrial ablation is a procedure that burns the glands in the lining of the uterus, which are usually shed each month as a period. The procedure is performed to make periods lighter. Endometrial ablation is successful approximately 75% of the time. Having endometrial ablation does NOT mean you can’t get pregnant. Contraception is still required until menopause is documented. If you do get pregnant after an endometrial ablation, there is a higher risk of miscarriage, preterm delivery, and problems with the placenta. The procedure has There are both benefits and risks.

If someone has anemia (low red blood cell count) due to heavy bleeding during their periods, this usually resolves.

Risks:

With any procedure, there is a risk of bleeding, infection, problems with anesthesia, or injury to surrounding structures. Uterine perforation (when an instrument goes through the uterine wall) can sometimes occur. If this happens, endometrial ablation cannot be performed, and rarely additional surgery will be necessary if there is a concern over injury to bladder, bowel, or blood vessels. The risk of any of the above complications is approximately 1%.

Occasionally, abnormal bleeding or pelvic pain can occur after endometrial ablation. This can occur several months to many years after the procedure. This happens 10% of the time, and may require additional evaluation and treatment.

Sometimes after endometrial ablation, the cavity of the uterus can form scar tissue. This happens approximately 30% of the time. Scar tissue can make it difficult to evaluate any abnormal bleeding that may occur, before or after menopause. Abnormal bleeding is often evaluated with an endometrial biopsy (when a catheter is put through the cervix and a brush is placed in the uterus to collect cells), which is performed in the office or by hysteroscopy (which is when we place a camera in the uterine cavity). For the women who have scarring in their uterine cavity after endometrial ablation, often an endometrial biopsy or hysteroscopy are not possible. In these cases, a hysterectomy may be recommended.

There is a possibility that if endometrial (uterine) cancer develops in the future, that there could be a delay in diagnosing it, which may affect survival. Usually, endometrial cancer presents with postmenopausal bleeding. If scarring occurs in the cavity which blocks blood from coming out the vagina, then there could be a delayed diagnosis. Anyone who has had an endometrial ablation should alert their physician if they have pelvic pain.

For women who have previously had their tubes tied, there is an 8% chance of pain occurring after having an endometrial ablation. This is called “post ablation tubal ligation pain syndrome”. It can occur months to years after the ablation. Usually the treatment is laparoscopic (surgical) removal of the uterus (hysterectomy) and tubes. If this is required, the ovaries are left in place, so the patient does not undergo instant menopause.

Conclusion:

Most women who undergo endometrial ablation are extremely happy that they chose ablation. However, you need to understand that ablation does not improve heavy bleeding in all patients, and there are risks involved during the procedure, and possible long-term complications.

Hysteroscopy

Hysteroscopy is a procedure that allows visualization of the inside of the uterus in order to diagnose and treat causes of abnormal bleeding. Hysteroscopy is done using a hysteroscope, a thin, lighted tube that is inserted into the vagina to examine the cervix and inside of the uterus. The procedure can be performed under local anesthesia (numbing of the cervix) or under IV sedation (twilight). Hysteroscopy is also used to perform Essure, a type of permanent sterilization.

Stop aspirin, ibuprofen (Advil, Motrin) and naproxen (Aleve) 1 week before surgery, as these medications increase the risk of bleeding

If you take any vitamins or herbs, stop them one week before surgery

Inform your doctor if you take Xaralto, Coumadin, Plavix, or Glucophage

You may take any blood pressure medications with a small sip of water the morning of the surgery. Do not take any other medication on the morning of the procedure. You may take them after you get home from the hospital.

Do not eat or drink anything after midnight the night prior to the procedures. If your surgery is scheduled for the afternoon, you may drink clear liquids (plain coffee, tea, apple/cranberry juice, water, lemonade, soda) up to 6 hours prior to the scheduled time of the procedure.

Postoperative instructions:

It is normal to have mild to moderate cramping. Take ibuprofen (Advil or Motrin), 600mg every 6 hours (3 pills every 6 hours), or Aleve, 2 pills every 12 hours. If you are still in pain, you may take Vicodin in addition to the ibuprofen or Aleve. If you are in severe pain despite taking these medications, please call the office. You are usually given a written prescription for Vicodin or another mild narcotic prior to surgery. Approximately 50% of patients will take 1-2 doses, and the other 50% are fine with ibuprofen alone. Do not drive if you are taking a narcotic.

Eat a bland diet the day of the procedure (nothing fatty, spicy, or fried). The following day, resume your normal diet.

You may resume exercise 2-3 days after the procedure, but listen to your body. If you are in pain, or note an increased in bleeding, please decrease your activity level.

Avoid taking baths or swimming for 1 week after surgery.

Light bleeding or spotting is normal for up to 2 weeks after surgery. Heavy bleeding where you are changing a pad an hour is not normal, and you need to call the office.

Please call the office if you have fever (temp > 100.4), persistent vomiting, or any significant concerns.

All surgery has risks. The risks include but are not limited to bleeding which may require a blood transfusion, infections, injury to surrounding structures, problems w/ anesthesia, blood clot in the leg, or nerve injury. With hysteroscopy, there is a risk that an instrument may go through the top of the uterus (uterine perforation). If this occurs, a laparoscopy may need to be performed (small incision in the belly button; look inside the abdomen with a small camera). If anything is injured (bowel, blood vessels, bladder), then I will repair it or call in a specialist to repair it). The risk of ANY of these complications occurring is approximately 1%.